emergency medicine pda

7/22/2019 Emergency Medicine PDA

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Emergency Medicine - Toronto NotesAbridged for the PDA

To be used only in conjunction with the printed Toronto NotesInitial

atient Assessment and Management

Dawn Lim, Chris McColl and Mildred Wong, chapter editors

John Hanlon and Andrea Mok, associate editors

Caroline Collins, EBM editor

Dr. Dan Cass, Dr. Margaret Thompson and Dr. Jeffrey Tyberg, staff editors

Initial Patient Assessment and Management1. Rapid Primary Survey

2. Resuscitation

3. Detailed Secondary Survey

4. Definitive Care

ToxicologyApproach to the Overdose Patient

ABCs of ToxicologyD1- Universal Antidotes

D2 - Draw Bloods

D3 - Decontamination

E - Examine the Patient

G - Give Specific Antidotes and Treatment

Enhanced Elimination

Disposition from the Emergency Department


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1. Rapid Primary Survey (RPS)

Airway maintenance with C-spine control Breathing and ventilation Circulation (pulses, hemorrhage control) Disability (neurological status) Exposure (complete) and Environment (temperature control) restart sequence from beginning if patient deterioratesIMPORTANT: always watch for signs of shock while doing primary survey

A. AIRWAY first priority is to secure airway assume a cervical (C-spine) injury in every trauma patient immobilize with

collar (ER 14) asses ability to breathe and speak ask patient a question; appropriate response indicates patient airway & ability to breathe signs of obstruction

agitation, confusion, universal choking signrespiratory distressfailure to speak, dysphoniaadventitious soundscyanosis

think about ability to maintain patency in future can change rapidly, REASSESS FREQUENTLY (especially if patient status changes)

Airway Management goals

permit adequate oxygenation and ventilationfacilitate ongoing patient managementgive drugs via endotracheal tube (ETT) if IV not available

N.B. start with basic management techniques before progressing to advanced

(see below)

1. Basic Airway Management (Temporizing Measures) protect the C-spine head-tilt chin lift or jaw thrust (if C-spine injury suspected) to open the airway sweep and suction to clear mouth of foreign material nasopharyngeal airway oropharyngeal airway (not if gag present) transtracheal jet ventilation (through cricothyroid membrane)

used as last resort, if unable to ventilate after using above techniques

2. Definitive Airway Management endotracheal intubation (ETI) with inline stabilization of spine (see Figure 1)

orotracheal Rapid Sequence Intubation (RSI)nasotracheal - may be better tolerated in conscious patient

does not provide 100% protection against aspiration contraindicated with basal skull fracture

indications for intubationunable to protect airway (e.g. GCS ? 8; airway trauma)inadequate oxygenation via spontaneous ventilation (O2saturation < 90% with

100% O2or rising pCO2)profound shockanticipate in trauma, overdose, congestive heart failure (CHF), asthma, and

chronic obstructive pulmonary disease (COPD)anticipated transfer of critically ill patients


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surgical airway (if unable to intubate using oral/nasal route)needed for chemical paralysis of agitated patients for investigationscricothyroidotomy

B. BREATHING

LOOK mental status (anxiety, agitation), colour, chest movement (bilateral orasymmetrical?), respiratory rate/effort, nasal flaring, LOC

LISTEN sounds of obstruction (e.g. stridor), breath sounds, symmetry of airentry, air escaping

FEEL flow of air, tracheal shift, chest wall for crepitus, flail segments, suckingchest wounds, subcutaneous emphysema

Breathing Assessment measurement of respiratory function: rate, pulse oximetry, ABG, A-a gradient, peak

flow rate

Management of Breathing treatment modalities:

nasal prongs ^simple face mask ^oxygen reservoir ^CPAP/BiPAPVenturi mask: used to precisely control O2deliveryBag-Valve mask and CPAP: to supplement ventilation

C. CIRCULATION

Definition of Shock inadequate organ and tissue perfusion (brain, kidney, extremities)

Clinical Evaluation rapidly assess for cause of shock clinical features of acute hemorrhage

early: tachypnea, tachycardia, narrow pulse pressure, reduced urine output,

reduced capillary refill, cool extremities and reduced central venouspressure (CVP)late: hypotension and altered mental status

Management of Hemorrhagic Shock secure airway and supply O2TREAT THE CAUSE OF THE SHOCK! control external bleeding

apply direct pressureelevate profusely bleeding extremities if no obvious unstable fractureconsider vascular pressure points (brachial, axillary, femoral)do not remove impaled objects as they tamponade bleedingtourniquet only as last resort

prompt surgical consultation for active internal bleeding infusion of 1-2 L of NS or RL as rapidly as possible replace lost blood volume at ratio of 3:1 (maintain intravascular volume) if inadequate response, consider ongoing blood loss (e.g. chest, abdomen, pelvis,

extremities) ^operative intervention required indications for blood transfusion

severe hypotension on arrivalshock persists following crystalloid infusionrapid bleeding

transfusion options with packed red blood cells (PRBCs)cross-matched (ideal but takes time)type-specific (provided by most blood banks within 10 min.)


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preferred to O-negative uncross-matched blood if both availableO-negative (children and women of child-bearing age)O-positive (everyone else) if no time for cross and matchanticipate complications with massive transfusions

transfusion options with fresh frozen plasma (FFP)used for clinical evidence of impaired hemostasis

ongoing hemorrhage and platelet count < 50,000, PT > 1.5 x normal range vasopressors

used if hypotension persists despite appropriate volume resuscitationdobutamine 2.0-20.0 mcg/kg/min for systolic BP over 100 mmHgdopamine 2.5-20.0 mcg/kg/min for systolic BP 70 to 100 mmHgnorepinephrine 0.5-30.0 mcg/kg/min for systolic BP < 70 mmHg

D. DISABILITY assess level of consciousness by AVPU method (quick, rudimentary assessment) size and reactivity of pupils movement of upper and lower extremities

E. EXPOSURE/ENVIRONMENT undress patient completely essential to assess all areas for possible injury keep patient warm with a blanket radiant heaters; avoid hypothermia


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2. Resuscitation

done simultaneously with primary survey attend to ABCs manage life-threatening problems as they are identified vital signs q 5-15 minutes ECG, BP and O2monitors Foley catheter and nasogastric (NG) tube if indicated order appropriate tests and investigations: may include CBC, lytes, BUN, Cr, glucose,

amylase, INR/PTT, -HCG, toxicology screen, cross & type

3. Detailed Secondary Survey

done after rapid primary survey problems have been addressed intended to identify major injuries or areas of concern head to toe physical exam and X-rays (C-spine, chest, pelvis - required in blunt trauma, consider T-

spine and L-spine)

HISTORY SAMPLE: Signs and Symptoms, Allergies, Medications, Past medical history, Last

meal, Events related to injury

PHYSICAL EXAMINATION

Head and Neck pupils

assess equality, size, symmetry, reactivity to light inequality suggests local eye problem or lateralizing CNS lesion

reactivity/level of consciousness (LOC)

reactive pupils + decreased LOC ^metabolic or structural cause

non-reactive pupils + decreased LOC ^structural cause

extraocular movements and nystagmus fundoscopy (papilledema, hemorrhages) palpation of facial bones, scalp tympanic membranes

Chest inspect for flail segment, contusion palpate for subcutaneous emphysema auscultate lung fields CXR

Abdomen immediate laparotomy if:

refractory shock with no other discernable causeobvious peritonitisincreasingly distended abdomenpositive diagnostic peritoneal lavage, FAST U/S or CT scan

rectal exam for gastrointestinal (GI) bleed, high riding prostate and anal tone (best todo during the log roll)

bimanual exam in females

Musculoskeletal (MSK) examine all extremities for swelling, deformity, contusion, tenderness log roll and palpate thoracic and lumbar spines pelvis: palpate iliac crests and pubic symphysis, pelvic stability (lateral, AP, vertical)


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Neurological Glasgow Coma Scale (GCS) see ER6 alterations of rate and rhythm of breathing are signs of structural or metabolic

abnormalitiesprogressive deterioration of breathing pattern implies a failing CNS

full cranial nerve exam assessment of spinal cord integrity

conscious patient: assess distal sensation and motor abilityunconscious patient: response to painful or noxious stimulus applied to

extremities


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4. Definitive Care

a. continue therapy b. continue patient evaluations (special investigations) c. specialty consultations including O.R. as needed d. disposition: home, admission, or another setting

Hypothermia

predisposing factors: old age, lack of housing, drug overdose, EtOH ingestion, trauma(incapacitating), cold water immersion, outdoor sports

clinical features include: mental confusion, impaired gait, lethargy, combativeness,shivering (eventually stops in severe cases)

may progress to unconsciousness, respiratory depression/arrest, cardiac arrest treatment based on: (a) re-warming and (b) supporting cardiorespiratory function

Re-warming Options Passive External Re-warming (PER):

suitable for most stable patients with core temperature > 32.2Cinvolves covering patient with insulating blanket; body generates heat and

re-warms through metabolic process, shivering Active External Re-warming (AER)

involves use of warming blankets, etc.beware afterdrop phenomenon (warming of extremities causes

vasodilation and movement of cool pooled blood from extremities to core,

resulting in a DROP in core temperature cardiac arrest)safer when done in conjunction with active core re-warming (below)

Active Core Re-warming (ACR)

generally for patients with core temperature


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Approach to the Overdose Patient

History How much? How long ago? What method? (ingestion, inhalation, dermal, ocular,

environmental, IV) accidental vs intentional exposure

Physical Exam focus on: ABCs, LOC/GCS, vitals, pupils

Principles of Toxicology 5 principles to consider with all ingestions

i. resuscitation (ABCs)ii. screening (toxidrome? clinical clues?)iii. decrease absorption of drugiv. increase elimination of drugv. antidote available?


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ABCs of Toxicology

basic axiom of care is symptomatic and supportive treatment address underlying problem only once patient is stable

A Airway (consider stabilizing the C-spine)B BreathingC CirculationD1 Drugs

ACLS as necessary to resuscitate the patient universal antidotes

D2 Draw bloodsD3 Decontamination (decreased absorption, increased elimination)E Expose (look for specific toxidromes)/Examine the PatientF Full vitals, ECG monitor, Foley, x-rays, etc.G Give specific antidotes, treatmentsGo back and reassess.Call Poison Control CentreObtain corroborative history from family


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D1 Universal Antidotes

treatments that will never hurt any patient and may be essential

Oxygen do not deprive an hypoxic patient of oxygen no matter what the antecedent medical

history (i.e. even COPD with CO2retention) if depression of hypoxic drive, intubate and ventilate exception: paraquat or diquat (herbicides) inhalation or ingestion

Thiamine (Vitamin B1) 100 mg IV/IM to all patients with IV/PO glucose a necessary cofactor for glucose metabolism, but do not delay glucose if thiamine

unavailable to prevent Wernicke-Korsakoff syndrome

Wernickes encephalopathy - Ataxia, Confusion, Ophthalmoplegia (WACO)untreated, may progress to Korsakoffs psychosis (disorder in learning and

processing of new information), usually irreversibletreatment: high dose thiamine (1000 mg/day x 3 days)

must assume all undifferentiated comatose patients are at risk

Glucose give to any patient presenting with altered LOC measure blood glucose prior to glucose administration adults: 0.5-1.0 g/kg (1-2 mL/kg) IV of D50W children: 0.25 g/kg (2 mL/kg) IV of D25W

Naloxone antidote for opioids: administration is both diagnostic and therapeutic (1 min onset of

action) used for the undifferentiated comatose patient loading dose

adults 2 mg initial bolus IV/IM/SL/SC or via ETT if no response after 2-3 minutes, increase dose by 2 mg increments until a

response or to max 10 mg known chronic user, suspicious history, or evidence of tracks, give

0.01 mg/kg (to prevent acute withdrawal)child

0.01 mg/kg initial bolus IV/IO/ETT 0.1 mg/kg if no response and narcotic suspected

maintenance dosemay be required because half-life of naloxone much shorter than many narcotics(half-life of naloxone is 30-80 minutes)hourly infusion rate at 2/3 of initial dose that produced patient arousal


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D2 - Draw Bloods

essential bloods (see Table 17 for interpretation)CBC, electrolytes, urea, creatinineglucometer, INR, PTTABGs, measured O2satosmolalityacetylsalicylic acid (ASA), acetaminophen alcohol levels

potentially useful bloodsdrug levels (toxicology screen)Ca2+, Mg2+, PO43protein, albumin, lactate, ketones and liver tests

Serum Drug Levels treat the patient, not the drug level negative tox screen signifies only that the specific drugs tested were not

detectable in the specimen at the time it was obtained (i.e. does not rule outa toxic ingestion)

specific drugs available on general screen vary by institution; check before ordering urine screens also available (qualitative only)

Table 17. Toxic Gaps (see Nephrology,NP16)Anion Gap (AG)= Na+ - (Cl- + HCO3-) normal range 10-14 mmol/L

Metabolic AcidosisIncreased AG: etiologies (* = toxic)MUDPILES CATMethanolUremiaDiabetic ketoacidosis/Starvation ketoacidosisPhenformin*/Paraldehyde*Isoniazid, iron, ibuprofenLactate (anything that causes seizures or shock)Ethylene glycol*Salicylates*Cyanide; carbon monoxide*

Alcoholic Ketoacidosis*Toluene; theophylline*Decreased AG1. error2. electrolyte imbalance (increased Na+/K+/Mg2+)3. hypoalbuminemia (50% fall in albumin

~ 5.5 mmol/L decrease in the AG)4. Li, Br elevation5. paraproteins (multiple myeloma)Normal AG1. K+: pyelonephritis, obstructive nephropathy, renal tubularacidosis (RTA), IV, TPN2. K+: small bowel losses, acetazolamide, RTA I, II

Plasma Osmolar Gap (POG)= measured calculated osmoles normally POG < 10 mOsm/L calculated osmlality = 2Na+ + BUN + blood glucose (mmol/L)

Plasma Osmolar GapsIncreased POG: MAE DIE (if it ends in -ol, it will likely the POG)MethanolAcetoneEthanolDiuretics (glycerol, mannitol, sorbitol)IsopropanolEthylene GlycolOxygen saturation gap= measured calculated O2sat measured by absorption spectrophotometry (pulse oximetry) calculated from Hb/O2saturation curve

Increased O2saturation gap carboxymethemoglobin methemoglobin sulfhemoglobin


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Table 18. Use of the Clinical Laboratory in the Initial Diagnosis of PoisoningTest Finding Selected Causes

ABG hypoventilation (6 pCO2) hyperventilation ( pCO2)

CNS depressants (opioids, sedative-hypnotic agents, phenothiazines, EtOH) salicylates, CO, other asphyxiants

Electrolytes anion-gap metabolicacidosis hyperkalemia

hypokalemia

MUDPILES CAT: see Metabolic Acidosis above digitalis glycosides, fluoride, potassium

theophylline, caffeine, -adrenergic agents, soluble barium salts, diuretics

Glucose hypoglycemia oral hypoglycemia agents, insulin, EtOH

Osmolality andOsmolar Gap

elevated osmolar gap MAE DIE; see Toxic Gaps above

ECG wide QRS complex prolonged QT interval atrioventricular block

TCAs, quinidine, other class Ia and Ic antiarrhythmic agents quinidine and related antiarrhythmics, terfenadine, astemizole Ca2+ antogonists, digitalis glycosides, phenylpropanolamine

Abdominal X-Ray radiopaque pills or objects CHIPES: Calcium, Chloral hydrate, CCl4, Heavy metals, Iron, Potassium,Enteric coated Salicylates, and some foreign bodies

Serum Acetaminophen elevated level(> 140 mg/L or 1000 m/L4 hours after ingestion)

may be only sign of acetaminophen poisoning


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D3 - Decontamination

Ocular Decontamination saline irrigation to neutral pH alkali exposure requires ophthalmology consult

Dermal Decontamination (wear protective gear) remove clothing brush off toxic agents irrigate all external surfaces

Gastrointestinal Decontamination activated charcoal (AC)

indications: single dose will prevent significant absorption of many drugs andtoxins

contraindications: acids, alkalis, cyanides, alcohols, Fe, Lidose = 1 g/kg body weight or 10 g/g drug ingestedodourless, tasteless, prepared as slurry with H2O

cathartics rarely used (risk electrolyte imbalance) whole bowel irrigation

500 mL (child) to 2000 mL (adult) of balanced electrolyte solution/hour bymouth until clear effluent per rectum

indications awake, alert patient who can be nursed upright delayed release product drug/toxin not bound to charcoal drug packages (if any evidence of breakage ^emergency surgery) recent toxin ingestion (up to 4-6 hours)

contraindications evidence of ileus, perforation, or obstruction

surgical removal

indicated for drugs that are toxic, form concretions, or are not removed byconventional means


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E - Examine the Patient

vital signs (including temperature), skin (needle tracks, colour), mucous membranes,odours and CNS

head-to-toe surveyC-spinesigns of trauma, seizures (incontinence, tongue biting, etc.), infection

(meningismus), chronic alcohol/drug abuse (track marks, nasal septum erosion) mental status

Table 19. Specific ToxidromesToxidrome Overdose Signs and Symptoms Examples of Drugs

hyperthermia Hot as a hare antidepressants (e.g. TCAs)

dilated pupils Blind as a bat cyclobenzaprine (Flexeril)

dry skin Dry as a bone carbamazepine

vasodilation Red as a beet antihistamines (e.g. diphenhydramine)

agitation/hallucinations Mad as a hatter antiparkinsonians

ileus The bowel andbladder lose

antipsychotics

urinary retention their tone and theheart

antispasmotics

Anticholinergics

tachycardia goes on alone belladonna alkaloids (e.g. atropine)DUMBELS cholinergic drugs

Diaphoresis, Diarrhea,Decreased blood

pressure

(nicotine,mushrooms)

Urination anticholinesterases

Miosis (physostigmine, organophosphate insecticides)

Bronchospasm,Bronchorrhea,Bradycardia

Emesis, Excitation ofskeletal muscle

Lacrimation

Cholinergics

Salivation, Seizures

dysphonia, dysphagia major tranquilizers

rigidity and tremor antipsychotics

motor restlessness, crawling sensation(akathisia)

constant movements (dyskinesia)dystonia (muscle spasms, laryngospasm, trismus,oculogyric

Extrapyramidal

crisis, torticollis)

Hemoglobin

Derangements

increased respiratory rate carbon monoxide poisoning

decreased level of consciousness (carboxyhemoglobin)

seizures drug ingestion (methemoglobin, sulfhemoglobin)

cyanosis unresponsive to O2

lactic acidosis

Narcotics, Sedatives/ hypothermia EtOH

Hypnotics, EtOH bradycardia, hypotension benzodiazepines

respiratory depression opiates (morphine, heroin, etc.)

dilated or constrictiedpupils (pinpoint inopiate OD)

barbiturates

CNS depressionSympathomimetics increased temperature amphetamines

CNS excitation (including seizures) caffeine

tachycardia, hypertension cocaine, LSD, PCP

nausea and vomiting ephedrine & other decongestants

diaphoresis thyroid hormone

dilated pupils sedative/EtOH withdrawal


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G Give Specific Antidotes and Treatments

Table 20. Protocol for Warfarin OverdoseINR Management< 5.0 reduce maintenance dose hold dose x 1

5.1 9.0 if no risk factors for bleeding, hold warfarin x 1-2 days and reduce maintenance doseOR

if rapid reversal required, Vitamin K 2 4 mg PO, repeat INR in 24 hr

additional Vitamin K 1 2 mg PO if INR still high (onset in 4 6 hr)

9.1 20.0 Vitamin K 3 5 mg PO, INR in 24 hr and additional Vitamin K if necessary

>20.0 fresh frozen plasma (FFP) 10 20 mL/kg

Vitamin K 10 mg IV over 10 min (IV Vitamin K only if life-threatening hemorrhage); onset ~ 2

hr

increase Vitamin K dosing (q4h)

phenobarbital (little evidence)

Table 21. Urine Alkalinization in ASA OverdosePlasma pH Urine pH Treatment

Alkaline Alkaline D5W with 20 mEq KCl/L + 2 amps HCO3-/L at 2 3 cc/kg/hr

Alkaline Acid D5W with 40 mEq KCl/L + 3 amps HCO3-/L at 2 3 cc/kg/hr

Acid Acid D5W with 40 mEq KCl/L + 4 amps HCO3-/L at 2 3 cc/kg/hr

Table 22. Specific Antidotes and TreatmentsToxin Treatment Considerations

Acetaminophen decontaminate often clinically silent; evidence of liver/renal damage delayed >24 hrs

N-acetylcysteine (Mucomyst; useaccording to

toxic dose >= 150 mg/kg (~ 7.0 g)

Rumack-Matthew dosing nomogram) monitor drug level immediately and @ 4 hrs post-ingestion; also liver

enzymes, INR, PTT, BUN, Cr

hypoglycemia, metabolic acidosis, encephalopathy poor prognosis

ASA decontaminate (10:1 charcoal-to-drug ratio)

monitor serum pH and drug levels closely

alkalinize urine (see Table 21); wanturine pH

monitor K+ level; may require supplement for adequate urine

= 7.55 alkalinization

hemodialysis may be needed if intractable metabolic acidosis, very

high levels, or end-organ damage (i.e. unable to diurese)

Anticholinergics supportive care see table 19 for signs and symptoms

Benzodiazepines flumazenil uses for iatrogenic BZ overdose, reversal of BZ sedation

adults: 0.3 mg iv q5min to max1.0g

contraindications: known seizure disorder, mixed OD, and

children: 10ug/kg as above, max0.3 mg

BZ dependence/chronic user

Beta Blockers glucagon: 50-100 ug/kg slow iv push symptoms start within 2 hours of ingestion

(5-10 mg for adults); then 70ug/kg/hr

atropine or isoproterenol if severe

Calcium Channel

Blockers

CaCl 1-4 g of 10% soln iv if BP order ECG, lytes (especially Ca++, Mg2+, Na+, K+)

atropine or isoproterenol if severe

other: high-dose insulin, inotropes or

aggressive supportive therapy

CO Poisoning hyperbaric 100% O2 disputed benefit of hyperbaric O2in mild-moderate cerebral

dysfunction

coma is still undisputed indication for hyperbaric O2

Cyanide lilly Kit (Amyl Nitrate, then NaNitrite): Na thiosulfate

Digoxin decontaminate (charcoal) use for life-threatening arrhythmias unresponsive to


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Digibind (digoxin-specific Abfragments)

conventional therapy, 6 hr serum digoxin >19 nmol/L, initial K+

20 vials if acute; 5-10 if chronic >5mM, ingestion >10 mg (adult) / >4 mg (child)

1 vial (40 mg) neutralizes 0 .6 mg oftoxin

common arrhythmias include V-fib, V-tach, and conduction blocks

Acute DystonicReaction

benztropine: 1-2mg im/iv then 2mg

po x 3 days OR

benztropine (Cogentin) haseuphoric effect and potential for abuse

diphenhydramine 1-2mg/kg iv then

25 mg po qid x 3 days

Heparin protamine sulfate

Insulin/oral

hypoglycemic

glucose iv / po via NG tube glyburide (Diabeta) carries highest risk of hypoglycemia among oral

glucagon: 1-2 mg im (if no access toglucose)

agents; consider octreotide in these cases

Ethanol gastric decontamination if ingestion< 1hr

very common in children (dehydrogenase pathway less active)

thiamine 100 mg im/iv mouthwash = 70% EtOH; perfumes and colognes = 40 - 60% EtOH

manage airway and circulatorysupport

order serum EtOH level and glucose level; treat glucose level

consider hemodialysis if serumEtOH > 500 mg/dL

appropriately


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Enhanced Elimination

Multi-Dose Activated Charcoal (MDAC)

absorption of drug/toxin to charcoal prevents availability and promotes fecalelimination

without charcoal, gut continuously absorbs toxins; MDAC interrupts theenterohepatic circulation of some toxins and binds toxin diffusing back intoenteral membrane from the circulation

MDAC can increase drug elimination (potentially useful for phenobarbitol,carbamazepine, theophylline, digitoxin, others)

dose varies; continue until nontoxic or charcoal stool

EXTRA-CORPOREAL DRUG REMOVAL (ECDR)

Criteria for Hemodialysis toxins that have:

water solubilitylow protein bindinglow molecular weightadequate concentration gradientsmall volume of distribution (Vd) or rapid plasma equilibration

removal of toxin will cause clinical improvement advantage is shown over other modes of therapy predicted that drug or metabolite will have toxic effects impairment of normal routes of elimination (cardiac, renal, or hepatic) clinical deterioration despite maximal medical support useful for toxins at the following blood levels:

alcohols methanol: > 15.6 mmol/L (> 25-50 mg/dL) ethylene glycol: > 8 mmol/L (> 50 mg/dL)

salicylates acute (within 6 h): > 7.2-8.7 mmol/L (> 100 mg/dL) chronic: > 4.3-4.8 mmol/L (> 60 mg/dL)

lithium acute (within 6 h): > 4.0 mmol/L chronic: > 2.5-4.0 mmol/L

bromine: > 15 mmol/Lphenobarbital: 430-650 mmol/L

chloral hydrate (trichloroethanol): > 200 mg/kg others include theophylline, carbemazepine, valproate, methotrexate


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Disposition from the Emergency Department

discharge home vs. prolonged E.D. observation vs. admission methanol, ethylene glycol

delayed onsetadmit and watch clinical and biochemical markers

TCAsprolonged/delayed cardiotoxicity warrants admission to monitored (ICU)

bedif asymptomatic and no clinical signs of intoxication: 6 hour E.D. observationadequate with proper decontaminationsinus tachycardia alone (most common finding) with history of OD warrants

observation in E.D. hydrocarbons/smoke inhalation

pneumonitis may lag 6-8 hoursconsider observation for repeated clinical and radiographic examination

ASA, acetaminophenif borderline level, get second level 2-4 hours after first

oral hypoglycemicsadmit all patients for minimum 24 hours if hypoglycemic

Psychiatric Consultation once patient medically cleared, arrange psychiatric intervention if required beware - suicidal ideation may not be expressed

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